This site aims to bring out the truth about the state of the NHS. We reveal the views of current and retired NHS professionals, doctors, nurses and managers in particular. This has never happened in a public domain before. We also report stories of interest in order to provide a context. Find out more..

Patients are being put at risk because most NHS trusts are using an obsolete IT operating system that no longer receives security updates, researchers have warned.

The trusts’ use of the old Windows XP system could enable hackers to steal patient data or take control of hospital infrastructure. Criminals have already used cyberattacks to hold hospitals to ransom and an NHS trust in Lincolnshire and East Yorkshire said this week that an attack in October led to the cancellation of more than 2,800 patient appointments, including operations.

Citrix, the software company, made freedom of information (FoI) requests to 63 NHS trusts, with 42 responding and 38 confirming that they still used XP.

Windows XP, introduced in 2001, has not received security updates from Microsoft since 2014. Security experts say that this leaves systems with significant vulnerabilities. Once a machine in a hospital’s network is compromised hackers can enter other systems to control equipment such as x-ray machines and target patient records.

A previous FoI request this summer indicated that around half of NHS trusts were last year hit by so-called ransomware attacks, where hackers lock down a hospital’s IT systems and demand payment. The trusts either denied that they had paid up or would not say.

Jamie Moles of Lastline, a malware-detection company, said: “It’s no surprise to hear that the cash-strapped NHS is still running Windows XP. While security remains a low priority for management, they will increasingly fall victim to these kinds of threats.

“While security remains a low priority for NHS management, they will increasingly fall victim to these kinds of threats, which wouldn’t be a serious problem except it results in cancellation of treatments whilst the affected systems are investigated and cleaned up.”

The Metropolitan Police also admitted yesterday that it is still using the 15-year-old XP software on almost 20,000 desktop computers.

The trouble with apologising, when you and your family don’t use the service, is evident. A cynical medical profession regards statements from highly paid administrators and politicians as sarcasm, or cynical below the belt humour. Politicians and medical administrators on £400,000 a year are likely to use private facilities for their nearest and dearest. they do not appreciate the reality of undercapacity rationing and the gradual removal of the safety net that Aneurin Bevan put In Place of Fear . Covertly rationing by cutting differing sized holes in the net in different post codes is unethical. No UK citizen knows what is unavailable to them. Therefore they cannot plan for the shortfall. It’s falling apart, and it’s going to get worse…

Hundreds of thousands of patients are waiting more than four hours on hospital trolleys as accident and emergency departments experience a fivefold increase in delays finding beds.

NHS officials warn that a sharp rise in “trolley waits” is likely to get worse over winter. Between October 2015 and September 2016, 473,453 emergency patients waited longer than four hours to be transferred to a bed — almost five times higher than in 2010-11, according to analysis by the BBC…..

Chris Moulton, of the Royal College of Emergency Medicine, said: “We simply don’t have enough [beds]. If you compare us to other European countries we are really short.”

•Patients are waiting longer to see a consultant. NHS waiting lists have grown in the past eight years from 2.35 million people waiting to start treatment led by a consultant in December 2008, to 3.7 million in September this year, according to a study by the Nuffield Trust and the Health Foundation.

The chief executive of NHS Scotland has apologised to patients who have waited longer than they should have to be treated. Paul Gray was speaking at the health committee in Holyrood in response to a report by Audit Scotland that found health boards have failed to meet seven out of eight key targets.

The convener Neil Findlay said that almost every witness that appeared before the committee raised issues over cuts to services and said: “What comment do you have to those patients who have been waiting longer for treatment than they should because seven out of those eight targets have been missed?”…

Hospitals have been ordered to end “eye-wateringly high” payments to stand-in bosses after a watchdog found that salaries of more than £400,000 have become routine.

Some temporary staff could avoid tax on their NHS pay under arrangements described by regulators as deeply unpalatable. Costly employees are not monitored properly and hospitals have little idea whether they are any good, according to NHS Improvement, the financial regulator…..

As if morale was not low enough. Now the MDU in its advice Dec 5th: Doctors advised on dealing with ‘intrusive’ social media advances. Many “heartsink” patients have personality disorders, and the over sympathetic GP collects more than their fair share. Tough love which demands patient autonomy rather than dependence is the answer, as it is with rationing in general. Stalking can occur with nurses and other primary health team workers as well..

Doctors have been advised to tighten their privacy settings on social media and to decline gifts from patients in order to discourage unwanted advances.

Social media has made doctors “more accessible than ever” to patients, the Medical Defence Union warned. The body, which represents doctors in legal disputes, has dealt with a hundred cases in the past five years involving patients who have attempted to advance a relationship beyond the doctor’s clinic.

Beverley Ward, a medico-legal adviser at the union, said that a handful of those cases had “involved the type of stalking behaviour where a doctor may need to involve the police”.

“If [patients’ advances] are not nipped in the bud . . . things can get out of hand,” she said.

The culture of fear and psychological gagging extends beyond the staff to patients and ex-staff. I and my wife had reason to complain recently but have not done so, as we know the culprit(s) will be scapegoated.. Fear rules. The staff still feel gagged…. We are a long way from a truly “learning” organisation.

The CQC protests that it has no powers to investigate individual cases. Many patients, bereaved relatives and whistleblowers are deeply frustrated that disclosures to the CQC have not resulted in change. On the contrary, if NHS staff whistleblow they may still be fired, gagged and blacklisted. The CQC has done little to deter gagging, despite having been advised to do so by Sir Robert Francis.

The CQC is poor value, and it is time to move on from the current model of regulation. What is vital is a safely resourced, truly independent investigation facility for learning from serious failures. The government is establishing a Healthcare Safety Investigation Branch that will carry out only 30 investigations a year. It may be able to withhold information from patients and families. This defeats the purpose. More radical changes are needed if NHS safety is to improve.

It is early diagnosis that matters, and that means experience GPs filtering symptoms, or inexperienced nurses requesting many unnecessary tests. Given the falling numbers of doctors and nurses, the implications for further improvement are expensive either way. Informed consent in the emotional atmosphere surrounding a new cancer diagnosis is difficult and time consuming. When metastases are already present the risk/return decision becomes very hard.. We don’t have the financial Perverse Incentives to over treat, but we seem to achieve it nevertheless, because of our unwillingness to be honest. This is an area where the greatest savings and improvement in quality of life could be made.

People with cancer are living longer now than 40 years ago. This is clearly good news. But how much of this improvement can we attribute to drug treatment? Not much, concludes Peter Wise this week in an article I humbly suggest all oncologists should read (doi:10.1136/bmj.i5792). The nearly 20% improvement in five year survival over the past four decades is probably mainly due to improved early diagnosis and treatment rather than developments in cytotoxic chemotherapy, he says. And patients are being badly misled by over-enthusiastic accounts of what chemotherapy can achieve. Many expect a cure. In reality they will gain on average only a few months of extra life.

The roots of this over-enthusiasm are sadly familiar but worth recounting in the specific highly charged and intensive context of cancer. Wise, a medical ethics consultant and former consultant physician, doesn’t mince his words. Unrepresentative, industry funded trials that use surrogate endpoints are part of the problem. So too are regulatory failures, perhaps explained by regulatory capture in which “the regulator risks being regulated by the industry that it has been appointed to regulate.”

Unjustified enthusiasm for cancer drug treatments comes at huge cost, financial and personal (including treatment related deaths and reduced quality of life), and increased risk of dying in hospital rather than at home. Many patients don’t realise that opting for supportive rather than active treatment—often called “refusal”—is an option and may give them longer as well as better quality life than chemotherapy. Conflicts of interest among clinicians compound their reluctance to have tricky conversations.

If improved survival is indeed largely due to early diagnosis and treatment, how is this best achieved? Many patients visit their GP with vague or non-specific symptoms. How should these be investigated and followed up without causing unnecessary alarm or wasting precious resources? As Brian Nicholson and colleagues explain (doi:10.1136/bmj.i5515), “safety-netting” aims to ensure that patients don’t drop through the healthcare net and are monitored until symptoms can be explained. But there is little evidence on whether this works or how to do it well. In particular, how much responsibility should patients be expected to take in chasing up and understanding test results? The authors encourage a sharing of this responsibility between clinicians and patients, but also clear communication and robust systems to prevent patients falling through the net.

Wise concludes with a call for higher bars for drug approval for new and existing drugs. Ethical cancer care demands empowerment of patients, he says, with accurate, impartial information followed by genuinely informed consent. And funds and attention should shift to prevention, early detection, prompt and radical treatment of localised and regional disease, and early provision of supportive care. Only then will cancer care serve patients rather than governments and industry.

‘You can declare war more peacefully than you can reform a healthcare system,” writes Ken Clarke in his memoir Kind of Blue. According to the former health secretary, hospital closures always provoke the bitterest battles. As soon as he embarked on a reorganisation in the 1980s he “became immersed in a constant round of demonstrations and petitions fighting to ‘save’ clapped-out institutions all over the country”.

On one occasion he had to force his way through a crowd holding placards outside a maternity hospital that was due to be shut. Although the local MP privately told him it had been a “terrible mistake” not to close the place years ago, and the senior obstetrician gave him his clinical view that it was “dangerous and unsuitable”, neither of them would back him up in public. Mr Clarke describes how a newborn baby born at the hospital was thrust into his arms as he addressed the protesters. “Clutching the baby nervously and hoping I was holding it the right way up I was then interviewed by the local television crew,” he recalls.

As affable as he is resilient, Mr Clarke relished every fight — his greatest dread was “a long, quiet, uncontroversial tenure of office in any department”. But even he was shaken by the hostility to hospital closures.

Now it will be Jeremy Hunt under fire. Having seen off the junior doctors’ strike, the health secretary is about to preside over a shake-up that will see hospitals closed, maternity units axed and A&E departments downgraded all over England. Although the details are still being finalised, it seems certain that thousands of hospital beds will disappear in the search for £22 billion of efficiency savings by 2020.

So far 33 out of 44 areas have published their “sustainability and transformation plans” and the rest must do so before Christmas. Under the proposals, which are out for consultation, one of the five acute hospitals in southwest London could close, along with three community hospitals in Leicestershire, four in Devon and three in Dorset. Other institutions will have services such as emergency stroke care removed as part of a drive to create specialist centres of excellence.

Theresa May has instructed Mr Hunt to prevent a high-profile row over hospital closures, but it’s hard to see how he can control the backlash. Even though the plans have been drawn up by local NHS bosses rather than ministers the government will still get the blame. Mass protests are inevitable as details of the changes are firmed up — indeed, 4,000 people recently marched against planned changes to Barnstaple hospital in Devon, and campaigners in Cumbria are warning that mothers and babies will die if they have to travel 40 miles from Whitehaven to Carlisle for care.

MPs, who are aware of the strength of public feeling, have already started to lobby the Department of Health to protect hospitals in their constituencies. They all remember the 18,000 parliamentary majority won by the independent candidate Richard Taylor in the Wyre Forest constituency at the 2001 election after he campaigned on the single issue of restoring the accident and emergency department at Kidderminster hospital.

Politicians are haunted by hospital closures, and the voters are fixated on protecting their local NHS, but we must all be rational rather than emotional about the provision of healthcare. There is a looming winter crisis in the health service and an impending disaster in social care as a result of local government cuts. The financial problems facing hospital trusts are matched by a growing workforce gap. Only a quarter of managers are confident they have the right mix of staff numbers, quality and skill to deliver proper healthcare, according to a survey published today by NHS Providers, which represents hospital trusts.

“However strongly people feel about their local NHS, the service cannot stand still,” says Chris Hopson, the chief executive. “There are thousands of people who are in a hospital bed who don’t need to be there.”

It is time to stop fetishising hospitals as the only way to deliver care and think about how best to allocate resources in the 21st century. It costs £400 a night to keep someone on a ward — money that could often be better spent elsewhere — but this isn’t just about cash. Nobody seriously wants to spend more time than they have to in an institution where they are at risk of infection and have no privacy. With long-term conditions such as dementia and diabetes eating up a growing proportion of the budget, money needs to be liberated from buildings and beds so that it can be redirected to looking after people at home.

In any case, the evidence — as opposed to the emotion — shows that centralising services can be the safest as well as the most efficient way to treat patients. In 2010, stroke units were closed in some London hospitals and resources concentrated in eight specialist centres. Despite the protests, almost 100 more people now survive every year as a result of the expert treatment they receive. After the centralisation of trauma care, the chances of surviving a serious accident have risen by 50 per cent.

Professor Naomi Fulop of University College London, who assessed the changes to stroke services in London, is convinced that this is a model that should be replicated around the country. “It may seem counterintuitive for an ambulance to drive a critical patient straight past the nearest hospital, but it saves lives,” she says.

In Grantham, the local hospital trust has announced that it is closing its A&E unit at night because it does not have enough doctors to run the department safely. With paramedics able to treat patients in the ambulance on the way to hospital, it may be better to have fewer A&E units but make sure those kept are properly staffed by experienced consultants.

Labour MPs who want to blame the Conservatives for hospital closures should remember that such a rationalisation was first proposed by the well-respected surgeon Lord Darzi, who became a health minister under Gordon Brown and is a Labour peer.

The crisis in health and social care means this is not a moment for local protectionism — a kind of nimbyism of the health service — nor for political short-termism from MPs who know what is needed but don’t want to admit it to their constituents. Closing hospitals may be the only way to save the NHS.

What do you think of the Welsh Government’s suggested response to the findings of the Diamond Review into student funding support in Wales? Is the Welsh Government right to accept the key proposals: that all students should receive a grant of at least £1,000 a year towards their daily living costs; that extra maintenance support should be provided on a means-tested basis so that the average student receives £7,000 a year; and that the current Tuition Fee Grant should be replaced with an additional student loan? In addition, can you let us know if you are happy with the way the Welsh Government is proposing to implement these proposals?

Deadline for responses: 16 January 2017

We have to be realistic in the funding, but there are greater issues to be dealt with:

Medical Recruitment and Training needs to change radically.

Changes need to address the gender imbalance as well as the lack of sufficient numbers.

NHSreality has suggested that several changes are needed.

1.Adverse selection whereby Medical Students are appointed from all over the country, and not simply from the outperforming suburban schools in richer post-codes.

2.Graduate entry to medical school will largely address the current gender imbalance.

3.A virtual Medical School in Wales and other areas of the UK whereby graduates are appointed into A General Practice for their training supervision, and which they address as their base. (they will then be more likely to integrate into a community)

4.Evidence based learning / tuition delivered “on line” for the most part. Written Exams also delivered on line. Orals and Physical Examinations will need centres, but these can be distributed or centralised.

5.Use GPs in Hospitals, especially to facilitate the interface of oncology and palliative care. The savings that could be made are fantastic.

In addition, following the meeting GPs from pembs attended earlier this year:

6.Exit interviews for all staff, depersonalized and summarized by an independent third party (HR) for Boards and the Minister.

7.Changing to an open and honest culture of “overt rationing”.

8.Depoliticize the decision making processes so that the crisis now on us, ignored for so long, never happens again.

9. At present every applicant who is good enough should be accepted into Medicine, wherever it is taught in the UK. We should be aiming at 10% excess